NR 511 LATEST EXAM QUESTIONS AND ANSWERS
Define diagnostic reasoning
Reflective thinking because the process involves questioning one's thinking to
determine if all possible avenues have been explored and if the conclusions that are
being drawn are based on evidence.
Seen as a kind of critical thinking.
What is subjective data?
Anything the patient tells you or complains of regarding their symptoms
Chief complaint
HPI
ROS
What is objective data?
Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.
Identify components of HPI
Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
Describe the differences between medical billing and medical coding.
Medical billing: process of submitting and following up on claims made to a payer in
order to receive payment for medical services rendered by a healthcare provider
Medical coding: the use of codes to communicate with payers about which procedures
were performed and why.
Compare and contrast the two coding classification systems that are currently
used in the US healthcare system.
, ICD: International classification of disease codes are used to provide payer info on
necessity of visit or procedure performed. Shorthand for pt's dx.
CPT: common procedural terminology codes offer the official procedural coding rules
and guidelines required when reporting medical services and procedures performed by
physician and non-physician providers. Must have corresponding ICD.
How do specificity, sensitivity, and predictive value contribute to the usefulness
of diagnostic data?
Specificity: ability of a test to correctly detect a specific condition. If a pt has a condition
but test is negative, it is a false negative. If pt does NOT have condition but test is
positive, it is false positive.
Sensitivity: test that has few false negatives. Ability of a test to correctly identify a
specific condition when it is present. The higher the sensitivity, the lesser the likelihood
of a false negative.
Predictive value: The likelihood that the pt actually has the condition and is, in part,
dependent upon the prevalence of the condition in the population. If a condition is highly
likely, the positive result would be more accurate.
Diagnostic tests can be used to confirm or rule out hypotheses.
Diagnostic tests may be used to screen for conditions.
Diagnostic tests may be used to monitor the progress in managing a chronic condition.
Discuss the elements that need to be considered when developing a plan.
Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
Describe the components of medical decision making in E&M coding.
Define diagnostic reasoning
Reflective thinking because the process involves questioning one's thinking to
determine if all possible avenues have been explored and if the conclusions that are
being drawn are based on evidence.
Seen as a kind of critical thinking.
What is subjective data?
Anything the patient tells you or complains of regarding their symptoms
Chief complaint
HPI
ROS
What is objective data?
Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.
Identify components of HPI
Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
Describe the differences between medical billing and medical coding.
Medical billing: process of submitting and following up on claims made to a payer in
order to receive payment for medical services rendered by a healthcare provider
Medical coding: the use of codes to communicate with payers about which procedures
were performed and why.
Compare and contrast the two coding classification systems that are currently
used in the US healthcare system.
, ICD: International classification of disease codes are used to provide payer info on
necessity of visit or procedure performed. Shorthand for pt's dx.
CPT: common procedural terminology codes offer the official procedural coding rules
and guidelines required when reporting medical services and procedures performed by
physician and non-physician providers. Must have corresponding ICD.
How do specificity, sensitivity, and predictive value contribute to the usefulness
of diagnostic data?
Specificity: ability of a test to correctly detect a specific condition. If a pt has a condition
but test is negative, it is a false negative. If pt does NOT have condition but test is
positive, it is false positive.
Sensitivity: test that has few false negatives. Ability of a test to correctly identify a
specific condition when it is present. The higher the sensitivity, the lesser the likelihood
of a false negative.
Predictive value: The likelihood that the pt actually has the condition and is, in part,
dependent upon the prevalence of the condition in the population. If a condition is highly
likely, the positive result would be more accurate.
Diagnostic tests can be used to confirm or rule out hypotheses.
Diagnostic tests may be used to screen for conditions.
Diagnostic tests may be used to monitor the progress in managing a chronic condition.
Discuss the elements that need to be considered when developing a plan.
Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
Describe the components of medical decision making in E&M coding.
